Diferencia entre revisiones de «Rapid sequence intubation»

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''See [[critical care quick reference]] for medication dosages by age and weight.''
''See [[critical care quick reference]] for pre-calculated medication dosages by age and weight.''
==Background==
==Background==
Rapid sequence intubation (RSI) is an airway management technique that produces immediate anesthesia via an induction agent as well as rapid paralysis via a neuromuscular blocking agent.
Rapid sequence intubation (RSI) is an airway management technique that produces immediate anesthesia via an induction agent as well as rapid paralysis via a neuromuscular blocking agent.
Línea 5: Línea 5:
==Premedication==
==Premedication==
===[[Atropine]]===
===[[Atropine]]===
''There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations''
''There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations<ref>Fleming B, McCollough M; Henderson SO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. Can J Emerg Med 2005;7(2):114-7</ref>''
 
*{{MedicationDose|drug=Atropine|dose=0.02 mg/kg, no minimum dose|route=IV|context=Premedication|indication=Rapid sequence intubation|population=Pediatric|notes=May prevent bradycardia}}
Dosing:
*0.02mg/kg, minimum dose 0.1mg<ref> AHA 2015 guidelines comparison [http://www.sca-aware.org/sites/default/files/comparison_chart_2015_aha_guidelines_for_cpr_and_ecc.pdf full text]</ref>
*May prevent bradycardia  
Relative indications:
Relative indications:
*Intubation in child < 1 yr old
*Intubation in child < 1 yr old
*Prior to a second dose of succinylcholine
*Prior to a second dose of succinylcholine
===[[Lidocaine]]===
===[[Lidocaine]]===
*1.5mg/kg
*{{MedicationDose|drug=Lidocaine|dose=1.5 mg/kg|route=IV|context=Premedication|indication=Rapid sequence intubation|population=Adult|notes=May lower ICP; need 5-10 min prior to RSI}}
*May lower ICP, but need 5-10 minutes prior to RSI
 
===[[Fentanyl]]===
===[[Fentanyl]]===
*3 mcg/kg
*{{MedicationDose|drug=Fentanyl|dose=3 mcg/kg|route=IV|context=Premedication|indication=Rapid sequence intubation|population=Adult|notes=Blunts sympathetic response (pretreat if concern for increased ICP/BP); should be the last agent given}}
*Blunts sympathetic response to intubation (pretreat if concern for increased ICP/BP, i.e. ICH, aortic dissection)
*Should be the last agent given


==Induction==
==Induction==
===[[Etomidate]]===
===[[Etomidate]]===
Dosing:
*{{MedicationDose|drug=Etomidate|dose=0.2-0.4 mg/kg|route=IV|context=Induction|indication=Rapid sequence intubation|population=Adult|onset=1 min|duration=3-8 min}}
*0.2-0.4mg/kg
*Onset - 1 min
*Duration - 30-60 min
Special Considerations:
Special Considerations:
*There is concern for adrenal suppression exists regarding etomidate dosing although clinically significant outcomes from transient depression has not been demonstrated. Effects may be greater for pediatric patients<ref>Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.</ref><ref> Dmello D et al. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138(6):1327-1332.</ref><ref>Scherzer D et al. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. J Pediatr Pharmacol Ther JPPT Off J PPAG. 2012;17(2):142-149. doi:10.5863/1551-6776-17.2.142</ref>
*There is concern for adrenal suppression exists regarding etomidate dosing although clinically significant outcomes from transient depression has not been demonstrated. Effects may be greater for pediatric patients<ref>Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.</ref><ref> Dmello D et al. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138(6):1327-1332.</ref><ref>Scherzer D et al. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. J Pediatr Pharmacol Ther JPPT Off J PPAG. 2012;17(2):142-149. doi:10.5863/1551-6776-17.2.142</ref>


===[[Versed]]===
===[[Midazolam|Versed]]===
*Dose: 0.2-0.3mg/kg
*{{MedicationDose|drug=Midazolam|dose=0.2-0.3 mg/kg|route=IV|context=Induction|indication=Rapid sequence intubation|population=Adult|display=Versed|onset=1-2 min|duration=30-60 min}}
*Onset - 1 to 2 min
*Duration - 30-60 min


===[[Propofol]]===
===[[Propofol]]===
*Dose: 1-3mg/kg
*{{MedicationDose|drug=Propofol|dose=1-3 mg/kg|route=IV|context=Induction|indication=Rapid sequence intubation|population=Adult|duration=10-15 min}}
*Duration - 10-15 min
 
===[[Ketamine]]===
===[[Ketamine]]===
*Dose: 1-2mg/kg IV or 3-4mg/kg IM
*{{MedicationDose|drug=Ketamine|dose=1-2 mg/kg|route=IV|context=Induction|indication=Rapid sequence intubation|population=Adult|duration=30 min}}
*Duration - 30 min
*{{MedicationDose|drug=Ketamine|dose=3-4 mg/kg|route=IM|context=Induction (IM)|indication=Rapid sequence intubation|population=Adult|duration=30 min}}


==Paralytics==
==[[Neuromuscular blocking agents|Paralytics]]==
===[[Succinylcholine]]===
===[[Succinylcholine]]===
Dosing:
*{{MedicationDose|drug=Succinylcholine|dose=1.5 mg/kg|route=IV|context=Paralytic|indication=Rapid sequence intubation|population=Adult|onset=45 sec|duration=4-6 min|notes=Age >10 years}}
*1.5mg/kg IV (>10 y/o)
*{{MedicationDose|drug=Succinylcholine|dose=2.0 mg/kg|route=IV|context=Paralytic|indication=Rapid sequence intubation|population=Pediatric|onset=45 sec|duration=4-6 min|notes=Age <10 years}}
*2.0mg/kg IV (<10 y/o)
*{{MedicationDose|drug=Succinylcholine|dose=4 mg/kg|route=IM|context=Paralytic (IM)|indication=Rapid sequence intubation|population=Adult|onset=2-3 min|duration=10-30 min}}
*4mg/kg IM  
 
**Onset: IV- 45s, IM - 2-3 min
**Duration: IV - 4-6min,  IM - 10-30min
===[[Rocuronium]]===
===[[Rocuronium]]===
Dosing:
*{{MedicationDose|drug=Rocuronium|dose=1.2 mg/kg|route=IV|context=Paralytic (RSI dose)|indication=Rapid sequence intubation|population=Adult|onset=60 sec|duration=25-60 min|notes=Intubation RSI dose}}
*1.2mg/kg (intubation RSI dose)
*{{MedicationDose|drug=Rocuronium|dose=0.6 mg/kg|route=IV|context=Paralytic (repeat)|indication=Rapid sequence intubation|population=Adult|notes=For repeat paralysis}}
*0.6mg/kg (for repeat paralysis)
 
*Onset - 60s
===[[Vecuronium]]===
*Duration- 25-60 min
*{{MedicationDose|drug=Vecuronium|dose=0.1 mg/kg|route=IV|context=Paralytic|indication=Rapid sequence intubation|population=Adult|onset=60-90 sec|duration=65 min|notes=Agent of choice for prolonged paralysis}}


===Vecuronium===
==Trauma RSI==
Dose:
*Consider decreasing induction agent dosage for hemodynamic compromise
*0.1mg/kg
*Paralytic dosage stays the same
*Onset - 60-90 seconds
*Fentanyl with ketamine and rocuronium may blunt hypertensive response to tracheal manipulation as compared to traditional etomidate and succinylcholine RSI<ref>Lyon RM et al. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015; 19(1): 134. Published online 2015 Apr 1. doi:  10.1186/s13054-015-0872-2.</ref>
*Duration - 65 minutes (95% complete recovery)
**Etomidate does not have analgesic properties
**However, etomidate and succinylcholine produces less hypotension
*Hemodynamically stable, normotensive, well perfusing
**Option 1: 0.3 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
**Option 2: 2 mcg/kg fentanyl PLUS 2 mg/kg ketamine PLUS 1 mg/kg rocuronium
*Hypotensive or poorly perfusing
**Option 1: 0.15 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
**Option 2: 1 mcg/kg fentanyl PLUS 1 mg/kg ketamine PLUS 1 mg/kg rocuronium


==7 Ps==
==7 Ps==
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*Nitrogen wash-out
*Nitrogen wash-out
**100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2
**100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2
**Apneic oxygenation with NC at 6L/min while setting up and increase to 15L/min once patient is sedated
**[[Apneic oxygenation]] with NC at 6L/min while setting up and increase to 15L/min once patient is sedated


===Pretreatment===
===Pretreatment===
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***Adrenal suppression is likely irrelevant with one-time dose
***Adrenal suppression is likely irrelevant with one-time dose
**[[Ketamine]] (1-4mg/kg)
**[[Ketamine]] (1-4mg/kg)
***Agent of choice for asthmatics
***Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock)
***Available in IM form
***Available in IM form
***Sympathomimetic
***Sympathomimetic
****Avoid in patient with increased ICP AND hypertension
****Avoid in patient with significant HTN
****Consider in patient with increased. ICP AND hypotension or normal BP
****Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP
**Midazolam (0.2mg/kg)
**Midazolam (0.2mg/kg)
***Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
***Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
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===Protection and positioning===
===Protection and positioning===
*Sniffing position
*Sniffing position
*in cervical spine immobilization, use bimanual laryngoscopy and consider adjuncts such as [[bougie]] or [[Video Laryngoscopy|video laryngoscopy]] if minimal blood in oropharynx


===Pass Tube===
===Pass Tube===
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===Postintubation management===
===Postintubation management===
*[[CXR]]
*[[CXR]]
*Non-violent restraints
*Head of bed to 30° elevation
*Check ABG 30 minutes post-intubation
*Sedation
*Sedation
**Benzos
**[[Benzos]]
***Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
***[[Lorazepam]] 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
***Midazolam 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
***[[Midazolam]] 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
**Propofol
**[[Propofol]]
***5-80mcg/kg/min (titrate q10min)
***5-80mcg/kg/min (titrate q10min)
*Analgesia
*[[Analgesia]]
**Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
**[[Fentanyl]] 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
*Paralysis (if needed)
*Paralysis (if needed)
**Vecuronium 10mg, then 7mg/hr
**[[Vecuronium]] 10mg, then 7mg/hr


==See Also==
==See Also==
*[[Intubation]]
*[[Delayed sequence intubation]]
*[[Vasopressors]]
*[[Critical care quick reference]]
*[[Critical care quick reference]]
*[[EBQ:Comparison of Succinylcholine and Rocuronium for RSI]]
*[[EBQ:Comparison of Succinylcholine and Rocuronium for RSI]]
{{Related Difficult Airway Pages}}
== Calculators ==
{{Ideal_Body_Weight_Calculator}}


==External Links==
==External Links==
*[http://pemplaybook.org/podcast/adventures-in-rsi/ Adventures in RSI - Pediatric Emergency Playbook]
*[http://pemplaybook.org/podcast/adventures-in-rsi/ Adventures in RSI - Pediatric Emergency Playbook]
*[https://www.merckmanuals.com/professional/critical-care-medicine/respiratory-arrest/drugs-to-aid-intubation?query=rapid%20sequence%20intubation Merk Manual - Drugs to Aid Intubation]
*[https://emcrit.org/pulmcrit/rapid-sequence-intubation-and-procedurization/ EMCrit - Rapid Sequence Intubation and Procedurization]


==References==
==References==
<references/>
<references/>
[[Category:Critical Care]]
[[Category:Critical Care]]
[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Pharmacology]]
[[Category:Pharmacology]]

Revisión actual - 15:06 21 mar 2026

See critical care quick reference for pre-calculated medication dosages by age and weight.

Background

Rapid sequence intubation (RSI) is an airway management technique that produces immediate anesthesia via an induction agent as well as rapid paralysis via a neuromuscular blocking agent.

Premedication

Atropine

There is no evidence to support the routine use of atropine as a premedication to prevent bradycardia in emergency pediatric intubations[1]

  • Atropine 0.02 mg/kg, no minimum dose IV — May prevent bradycardia

Relative indications:

  • Intubation in child < 1 yr old
  • Prior to a second dose of succinylcholine

Lidocaine

  • Lidocaine 1.5 mg/kg IV — May lower ICP; need 5-10 min prior to RSI

Fentanyl

  • Fentanyl 3 mcg/kg IV — Blunts sympathetic response (pretreat if concern for increased ICP/BP); should be the last agent given

Induction

Etomidate

  • Etomidate 0.2-0.4 mg/kg IV (onset 1 min, duration 3-8 min)

Special Considerations:

  • There is concern for adrenal suppression exists regarding etomidate dosing although clinically significant outcomes from transient depression has not been demonstrated. Effects may be greater for pediatric patients[2][3][4]

Versed

  • Versed 0.2-0.3 mg/kg IV (onset 1-2 min, duration 30-60 min)

Propofol

  • Propofol 1-3 mg/kg IV (duration 10-15 min)

Ketamine

Paralytics

Succinylcholine

Rocuronium

  • Rocuronium 1.2 mg/kg IV (onset 60 sec, duration 25-60 min) — Intubation RSI dose
  • Rocuronium 0.6 mg/kg IV — For repeat paralysis

Vecuronium

  • Vecuronium 0.1 mg/kg IV (onset 60-90 sec, duration 65 min) — Agent of choice for prolonged paralysis

Trauma RSI

  • Consider decreasing induction agent dosage for hemodynamic compromise
  • Paralytic dosage stays the same
  • Fentanyl with ketamine and rocuronium may blunt hypertensive response to tracheal manipulation as compared to traditional etomidate and succinylcholine RSI[5]
    • Etomidate does not have analgesic properties
    • However, etomidate and succinylcholine produces less hypotension
  • Hemodynamically stable, normotensive, well perfusing
    • Option 1: 0.3 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
    • Option 2: 2 mcg/kg fentanyl PLUS 2 mg/kg ketamine PLUS 1 mg/kg rocuronium
  • Hypotensive or poorly perfusing
    • Option 1: 0.15 mg/kg etomidate PLUS 1.5 mg/kg succinylcholine
    • Option 2: 1 mcg/kg fentanyl PLUS 1 mg/kg ketamine PLUS 1 mg/kg rocuronium

7 Ps

Preparation

  • SOAPME: (Suction, oxygen, airway, pharmacology, monitoring, equipment)

Preoxygenation

  • Nitrogen wash-out
    • 100% NRB for 3-5min or 8 VC breaths (BVM) with high-flow O2
    • Apneic oxygenation with NC at 6L/min while setting up and increase to 15L/min once patient is sedated

Pretreatment

  • Ischemic heart disease/dissection: Fentanyl 3-5mcg/kg
  • Increased ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it))
  • Reactive Airway disease: Lidocaine 1.5mg/kg (suppresses cough reflex)
  • Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1mg, max 0.5mg)
    • Controversial

Paralysis with induction

  • INDUCTION
    • Etomidate (0.3mg/kg)
      • Especially good for hypotensive/trauma patients
      • Hemodynamically neutral, lowers ICP
      • Lowers seizure threshold in patients with known seizure disorder
      • Does NOT blunt sympathetic reaction to intubation (no analgesic effect)
      • Adrenal suppression is likely irrelevant with one-time dose
    • Ketamine (1-4mg/kg)
      • Agent of choice for asthmatics as it has bronchodilator effects. Also consider with hypotension (i.e.: septic shock)
      • Available in IM form
      • Sympathomimetic
        • Avoid in patient with significant HTN
        • Evidence for clinically significant rise in ICP equivocal at best. Consider use in head injured patients with increased ICP AND low or normal BP
    • Midazolam (0.2mg/kg)
      • Consider in patient with CHF (nitro-life effect → decrease ventilator filling pressure)
      • Consider in patient in status epilepticus (anti-seizure effect)
      • May decrease MAP, especially if patient hypovolemic
    • Propofol (1.5 to 3mg/kg)
      • Consider in patient with bronchospasm
      • Decreases MAP, CPP
  • PARALYSIS
    • Succinylcholine
      • 1.5mg/kg - better to overdose than to underdose
      • 2mg/kg - neonates/infants
    • Contraindications
      • Stroke <6 months old, MS, muscular dystrophies
      • ECG changes consistent with hyperkalemia
      • OK to use in crush injury, acute stroke as long as within 3 days of occurrence
    • Rocuronium
      • 1-1.2mg/kg
    • Consider not paralyzing in these situations
      • Expanding neck hematoma, to keep integrity of strap muscles
      • Unable to BVM due to facial hair, micrognathia
      • Unable to move to cricothyroidotomy (angioedema, goiter, anterior neck mass)

Protection and positioning

  • Sniffing position
  • in cervical spine immobilization, use bimanual laryngoscopy and consider adjuncts such as bougie or video laryngoscopy if minimal blood in oropharynx

Pass Tube

  • Intubation
  • End-tidal CO2 detection is primary means of ETT placement confirmation
  • Cola-complication: need CO2 detection for at least 6 ventilations

Postintubation management

  • CXR
  • Non-violent restraints
  • Head of bed to 30° elevation
  • Check ABG 30 minutes post-intubation
  • Sedation
    • Benzos
      • Lorazepam 1-4mg bolus; then 0.01-0.1mg/kg/hr (titrate q1hr)
      • Midazolam 1-5mg bolus; then 0.04-0.2mg/kg/hr (titrate q1hr)
    • Propofol
      • 5-80mcg/kg/min (titrate q10min)
  • Analgesia
    • Fentanyl 1-2mcg/kg bolus; then 25-250mcg/hr (titrate q20min)
  • Paralysis (if needed)

See Also

Airway Pages

Calculators

Ideal Body Weight

Ideal Body Weight / Adjusted Body Weight
Parameter Value
Sex 1 Male   Female
Height (inches) — total inches, e.g. 70 for 5'10"
Actual Weight (kg) — for adjusted BW
Results
Ideal Body Weight (Devine) kg
Adjusted Body Weight (IBW + 0.4 × [ABW − IBW]) kg
References
  • Devine BJ. Gentamicin therapy. Drug Intell Clin Pharm. 1974;8:650-655.
  • Male IBW = 50 kg + 2.3 kg per inch over 5 feet.
  • Female IBW = 45.5 kg + 2.3 kg per inch over 5 feet.
  • Adjusted BW = IBW + 0.4 × (Actual BW − IBW). Used for drug dosing in obese patients (e.g., vancomycin, aminoglycosides).
  • Tidal volume dosing: Use IBW for ventilator settings (6–8 mL/kg IBW per ARDSNet protocol).

External Links

References

  1. ↑ Fleming B, McCollough M; Henderson SO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. Can J Emerg Med 2005;7(2):114-7
  2. ↑ Sokolove PE et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care. 2000;16(1):18-21.
  3. ↑ Dmello D et al. Outcomes of etomidate in severe sepsis and septic shock. Chest. 2010;138(6):1327-1332.
  4. ↑ Scherzer D et al. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. J Pediatr Pharmacol Ther JPPT Off J PPAG. 2012;17(2):142-149. doi:10.5863/1551-6776-17.2.142
  5. ↑ Lyon RM et al. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015; 19(1): 134. Published online 2015 Apr 1. doi: 10.1186/s13054-015-0872-2.
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